How should a chalazion be managed in an HIV‑positive patient, including considerations for CD4 count and risk of infection?

Chalazion Management in HIV-Positive Patients

In HIV-positive patients, manage chalazion with conservative therapy (hot compresses ± topical antibiotics) for lesions present less than 2 months, but proceed directly to incision and curettage or intralesional steroid injection for older lesions, while avoiding intralesional steroids if CD4 count is below 200 cells/mm³ due to increased infection risk.

Initial Assessment and Risk Stratification

When evaluating a chalazion in an HIV-positive patient, immediately assess:

• CD4 count status: Patients with CD4 <200 cells/mm³ have significantly increased risk of opportunistic infections and atypical presentations 1
• Duration of the lesion: Chalazia present >2 months are significantly less likely to resolve with conservative therapy (p=0.04) 2
• Presence of atypical features: Rule out malignancy (conjunctival squamous cell carcinoma can masquerade as chalazion in HIV patients) or opportunistic infections 3
• Associated follicular conjunctivitis: May indicate viral etiology requiring different management 4

Treatment Algorithm Based on CD4 Count and Lesion Duration

For Lesions <2 Months Duration with CD4 >200 cells/mm³:

• First-line conservative therapy: Hot compresses alone, or hot compresses plus topical tobramycin, or hot compresses plus tobramycin/dexamethasone for 4-6 weeks 2
• All three conservative approaches show equivalent efficacy with approximately 18-21% complete resolution rates and mean size reduction of 1.2-1.7mm 2
• No significant difference exists between adding antibiotics or steroid drops to hot compresses alone (p=0.78 for resolution, p=0.61 for size reduction) 2

For Lesions >2 Months Duration or CD4 <200 cells/mm³:

• Proceed directly to surgical intervention: Incision and curettage is preferred over intralesional steroids in severely immunosuppressed patients 2
• Avoid intralesional corticosteroids when CD4 <200 cells/mm³ due to risk of local immunosuppression and potential for disseminated infection 1
• Lesions present >2 months have statistically significant lower resolution rates with conservative therapy (pretreatment duration 2.2 months for non-resolving vs 1.5 months for resolving lesions, p=0.04) 2

Critical Considerations for Immunosuppressed Patients

Drug Interactions and Immunosuppression:

• Monitor for azole interactions: If systemic antifungal therapy is needed for opportunistic infections, be aware that itraconazole and fluconazole interact with antiretroviral agents 1
• Assess overall immune status: The prevalence of onychomycosis and other infections correlates with CD4 counts <150 cells/mm³, indicating broader immunosuppression 1
• Consider cumulative immunosuppression: Avoid adding topical or intralesional steroids if patient is already on systemic immunosuppressive therapy 1

Atypical Presentations Requiring Biopsy:

• Young patients with persistent lesions: Consider excision biopsy to rule out conjunctival squamous cell carcinoma, which can present as chalazion-like swelling in HIV-positive patients 3
• Associated follicular conjunctivitis: May indicate viral-induced chalazion; intralesional corticosteroids should be avoided in these cases 4
• Rapid progression or unusual features: Obtain tissue diagnosis to exclude opportunistic infections or malignancy 3

Monitoring and Follow-Up

• Reassess at 2-4 weeks if conservative therapy is chosen 2
• Switch to surgical management if no improvement after 4-6 weeks of conservative therapy 2
• Coordinate with HIV specialist if CD4 count is declining or viral load is uncontrolled 1
• Consider immune reconstitution: Patients achieving CD4 >350 cells/mm³ on antiretroviral therapy may be managed more similarly to immunocompetent patients 1

Common Pitfalls to Avoid

• Do not delay surgical intervention for chalazia >2 months duration, as conservative therapy becomes progressively less effective 2
• Do not use intralesional steroids in patients with CD4 <200 cells/mm³ without infectious disease consultation 1
• Do not assume typical chalazion in HIV-positive patients without considering atypical presentations like squamous cell carcinoma 3
• Do not ignore associated follicular conjunctivitis, which may indicate viral etiology requiring modified management 4